Outcomes of a mentored research competition for authoring pediatric case reports in chiropractic

Case reports have two common characteristics: they describe the events of an interesting healthcare case and they provide new information for clinicians.¹  Case reports reside lower on the evidence hierarchy due to their inherent inability to be generalized to larger populations.²  However, for some research topics, case reports can add value, especially for generating hypotheses and safety data.

Interest in advanced education in the field of pediatrics has increased over the past two decades within the chiropractic profession.³  Currently, two postgraduate clinical pediatric diplomate programs aim to enhance clinical knowledge for doctors of chiropractic who seek to treat children.^4,5  A chiropractic pediatric specialist often describes encounters with novel clinical findings not found currently in the literature. Additionally, the process of writing about the novel clinical findings in a case report is a hands-on educational experience in scholarly writing and critical evaluation of the literature.

The challenge of authoring a paper, even to an experienced clinician, can be intimidating. Therefore, this project was designed to ease the anxiety of developing and writing a case report for practicing clinicians who were inexperienced authors. For this, we invited experienced chiropractors, board certified in pediatrics (Diplomates in Clinical Chiropractic Pediatrics, or DICCPs) to take part in a pediatric research competition with an opportunity to work with a mentor experienced in scientific writing, if necessary. The DICCP program was chosen because it was endorsed by the International Chiropractors Association (ICA) and the American Chiropractic Association's (ACA) Council on Chiropractic Pediatrics (CCP). All scientific literature submitted was peer reviewed, and considered for oral and/or poster presentation at the first pediatric conference jointly sponsored by the ICA and ACA's CCP in December 2011, and preliminarily accepted for publication in the Journal of Clinical Chiropractic Pediatrics.

The main initiatives for this competition were to enhance the existing literature base in chiropractic pediatrics, and to help establish a relationship between mentors knowledgeable in scientific writing and practitioners with clinical data. The purpose of this article is to explain the steps used to conduct this project, and to discuss the quantitative and qualitative outcomes regarding the experience of the mentors and clinicians.

As shown in Figure 1, the first step was the identification of DICCP clinicians (or postgraduate DICCP students) with potential cases to write about and experienced scientific writers who were willing to assist with this project. A letter was sent by mail inviting each DICCP graduate and student (n = 243) to participate. This then was followed up by two emails. Individual mentors were invited to participate either in person, via telephone conversation, or by email. Potential mentors were sought from the Palmer College of Chiropractic faculty, staff, or fellows in the Masters of Science in clinical research program. These mentors were handpicked because they either had personal experience writing or training on how to write a case report and, for convenience purposes, were at the same institution as two of the project organizers. Once solicited to be a co-author, mentors were given the opportunity to choose cases that interested them, based on topic, and the clinician's research and writing experience ascertained from the clinician's preparticipation survey, which is described below. Paired mentors and clinicians then were introduced to each other through e-mail and encouraged to set up a wiki, a website that allows multiple users to collaborate on a single document, to assist with writing the manuscript.

Guidelines for the one-on-one mentorship model were left fluid so that each relationship could have the flexibility to reflect the individual personalities. Mentors were described in orientation material as guides and references, but they were not expected to take full responsibility for the paper. Authorship guidelines were for the first author to: (1) take primary responsibility for all aspects of the paper; (2) write the paper in consultation with the second author; (3) maintain ownership of the master document; (4) submit the paper and manage manuscript correspondence; and (5) be responsible for archiving and documenting all data and files. The second author's responsibilities included: (1) making early decisions about the design of the paper; (2) keeping the paper on track in terms of the main messages; (3) making intellectual contributions to any data analyses; (4) contributing to the interpretation of the results, discussion, and conclusion; (5) reviewing each draft; and (6) taking public responsibility for the content and results.

All of the submitted case reports were evaluated independently by three reviewers using an evaluation rubric (Table 1). The results of each reviewer were summed and the total score was used as each case report's overall score. The overall scores then were sent to the three independent reviewers to ensure that all reviewers felt that these scores were fair. There were no discrepancies with the overall scores and there was full consensus that all the original overall scores were final. The authors of the 5 top-scoring case reports were invited to give an oral and poster presentation, and all other authors were invited for poster presentation. All submitted publications were to be accepted tentatively into the Journal of Clinical Chiropractic Pediatrics. ChiroSecure (Scottsdale, AZ) was the official sponsor for the competition, awarding the mentor and clinician $500 for first place and $250 each for second place.

Two surveys were conducted throughout this project, both of which were designed by the project organizers for the purposes of this study alone. The first was a preparticipation survey given to clinicians who needed a mentor (n = 10), which aimed to obtain information about their intended research and prior writing experience. The results of the survey remained anonymous to mentors until after all teams were paired. The second confidential survey was completed by mentors and clinicians upon completion of the project. This survey was intended to ascertain from the participants their thoughts about their experience in the project and anything that could be improved with future projects. Descriptive statistics from both surveys were analyzed using SPSS 15.0 (SPSS Inc, Chicago, IL).

This project also used focus groups to explore the qualitative aspects of the mentor–mentee relationship. Two focus groups were conducted with the same semistructured interviews given to mentees and mentors separately (Fig. 2). The mentees' focus group occurred at the conference before the oral presentations and competition results, while the mentors' focus group occurred the month following the pediatrics conference. Two independent reviewers read the transcripts and consensus was reached on emerging themes. The surveys and the focus group interviews were deemed exempt by the Palmer College of Chiropractic institutional review board.

A total of 14 potential research topics was submitted initially by DICCP clinicians or DICCP postgraduate students. Ten were case reports that required a mentor (Fig. 1), two potential topics were excluded, and two did not require a mentor (one was a narrative review and one was a case report). A presurvey was completed by the 10 case report authors who required a mentor.

One of the questions asked on the preparticipation survey was “What is the status of your proposed research topic”? Two authors' case-study subjects still were under care, six case-study subjects' care were complete, and two authors had manuscripts that already were started. The initial questionnaire also asked about the clinician's prior writing experience and time spent reading scientific literature. Professional literature was read often by nine of ten respondents, and scientific literature was read by eight of ten. Half of the survey respondents stated they had written professional and scientific literature. Of these, six professional papers and five scientific manuscripts were noted.

Postparticipation surveys were completed by five clinicians (50% response rate) and six mentors (75% response rate). Table 2 describes the overall experience of the clinicians and mentors. Clinicians spent an average of 58 hours (range 2–105) on this project, with the majority of that time spent reviewing the literature. Mentors spent an average of 36 hours (range 2–70) on this project with the majority of their time reviewing the literature and editing manuscripts. Mentees identified the mentors' strongest contributions as aiding their co-authors with addition of content material, editing the manuscript, and educating their co-authors about the scientific writing process. Overall, this project experience was rated as “excellent” or “good” by 64% of the participants and 73% noted they would participate in this project again.

Additionally, the postparticipation survey contained questions regarding the quality of the clinician–mentor relationship (Table 3). Overall, the relationships were friendly and supportive with a variety of results regarding availability, helpfulness, sympathetic, considerate, and flexible. Written comments about how this project could be improved included having defined guidelines on research topic, not encouraging the use of the wiki, and more structured guidelines of mentor and clinician expectations.

From the ten mentored case reports, eight papers were submitted. Two were withdrawn from the study (1 for lack of time to complete and 1 for an unknown reason). All submissions (Fig. 3) were reviewed by three independent reviewers using an evaluation rubric and were invited to present their work in a poster format at the conference held in December 2011, while the top five submissions were selected for oral presentations. The top two manuscripts were chosen to receive a monetary award. Table 3 outlines the mean and range results of the independent reviews for each criterion. Overall, the average score was 131 of 165 points (range 101–154).

Four main themes emerged during the focus groups: (1) motivation to participate, (2) communication, (3) mentee–mentor relationship, and (4) future directions. Motivation to participate as a mentee originated from either academic (chiropractic faculty member or DICCP student) or professional responsibility. Mentors' motivation to participate stemmed from the potential for a collaborative learning opportunity from a distance or desire to participant in an important service project. The wiki was the most common communication discussion topic. Those who used the wiki found that it was very useful, although most individuals found that it was more of an issue to learn a new process and preferred other modes of communication, including email and telephone. Some mentees wished they had the opportunity to have at least one face-to-face meeting.

The mentee–mentor relationships varied greatly, ranging from a very respectful and grateful situation to one that was not useful and necessitated other collegial resources. For a few mentors, this was their first opportunity to mentor another individual, while others had been involved in scientific mentoring relationships for several years. The new mentors struggled with the responsibilities included in this role. Some were of little help/guidance, while others were too helpful and completed tasks that most likely should have been completed by the mentee (e.g., literature searches and critical appraisal). Well-established mentors also had the best mentee–mentor relationship according to the mentee and mentor themselves.

All of the mentees expressed desire to be involved in research. For some of them, this experience demonstrated to them how research could be done, while others realized how much work it actually required. Ideas, such as a practice-based research network and systematic literature reviews, were expressed as future directions in which the mentees could move toward. The established mentors thought that this was a great service project and that they could take on two to four mentees at one time. Additional comments included the need for clearer mentoring guidelines.

Several methods have been used to increase the publication rate of faculty and clinicians, including support groups,^6,7  writing workshops and support groups,⁸  writing coaches,⁹  and peer mentoring.¹⁰  We chose to use the mentor model, since the DICCP clinicians were geographically distant. A mentor is defined as an influential supporter or a wise and trusted instructor.¹⁰  This project was innovative and, to our knowledge, the first within the pediatric chiropractic specialty designed to establish a mentor–clinician relationship that could facilitate production of a high-quality case report, thus adding value to the pediatric chiropractic body of literature. This project generated nine case reports and one narrative literature review, educated clinicians on the scientific writing process, and gave established scientific writers an opportunity to educate others. Currently, eight of the ten papers have been published in two recent issues of the Journal of Clinical Chiropractic Pediatrics (volume 12, number 20 and volume 13, number 1), and the last two are planned for the upcoming edition.^11–18  From the results of the postsurvey, the overall experience was “good,” but there are many opportunities for this to be improved upon.

Benefits of a mentor are well documented outside the chiropractic profession and mentors have become increasingly popular within chiropractic student clinics.^19,20  Effective mentoring requires mutual respect, trust, understanding, and empathy, where a mentor can share learned lessons and technical expertise.²¹  Additionally, the relationship requires a significant amount of attention and time from both involved parties. A wide variety of relationships was experienced within this project. From the survey, the mentees found the mentors to be “somewhat” to “very valuable” to the extent that all but one felt confident that they could write another research paper on their own. Data from the focus groups suggested experienced mentors were better suited for a project like this that involved distance communication and instruction of complex skills (e.g., critical appraisal and scientific writing).

Improvements to this project include setting up more structured guidelines, formulating an application process for potential clinicians or mentors, obtaining mentors from other institutions, and defining clearly the expectations of the paper submission and presentations. These additional processes are feasible with the continued support of sponsors, associations, colleges, mentors, and clinicians. Continuation of the improved project will enhance clinician's understanding of the research process and will facilitate the addition of high-quality literature to the body of chiropractic evidence.

Overall, this project had methods that can be replicated for any profession and topic. Communication of expectations is essential to the mentor and mentee (clinician). The methods and results were not designed to be a rigorous research project, but rather a community-based project in which the outcomes (i.e., case reports) were publishable. However, because of its success, the authors believed describing the methods and overall outcome of the project are valuable to others interested in conducting a similar project. The overall limitations include questionnaires that were designed for the needs of the study alone, but did not have established psychometric properties, and that the mentors and mentees were derived from a small group.

This project was designed to establish a mentor–clinician relationship that would produce scientific literature to be presented at the first joint pediatric conference in December 2011. A total of ten papers was submitted. Time spent on this project for the clinicians ranged from 20–105 hours and 2–70 hours for mentors. The overall experience was rated as “good” and 73% of the survey respondents stated that they would take part in a project like this again. This project ultimately fulfilled the goal of producing quality case reports using a mentorship model to facilitate scientific writing education in the field of chiropractic pediatrics.

The authors would like to thank the ICA and the ACA Councils on Pediatric Chiropractic for supporting this project and allowing it to debut at the first Joint Pediatric Conference. We thank ChiroSecure for their generous donation to reward the first and second place case reports. We also acknowledge the following individuals: Cheryl Hawk, DC, PhD, who was vital in the creation of the project and as a reviewer for the end products; Dana Lawrence, DC, MMedED, MA, who provided continuous support for the project throughout its creation, to publication, and year 2 competition evolution; Stacie Salsbury, RN, PhD, who provided qualitative methodology support and thematic analysis of the qualitative interview; Jennifer Weskunas, DC, who transcribed the qualitative interviews; Beverly Harger, DC, who was instrumental in the brainstorming of this project; and all the mentees and mentors (Navine Haworth, DC; Stephanie Willis, BAppSC/BChiroSc; Jennifer Murphy, DC; Peri Dwyer, DC; Carol Parnell, DC; Angie Frankeni, BAppSC/BChiroSc; Donna Quezeda, DC; Karen Gregory, DC; Jennifer Brocker, DC; Monisa Brown, DC; CJ Woslager, DC, MS; Robert Rowell, DC, MS; Andrea Haan, DC, MS; Connie Mitchell, DC; Amin Neekomand, DC; James Boysen, DC, MS; Casey Crisp, DC, MS; Christopher Roecker, DC).

The authors declare that they have no conflict interests.